Pediatric crowns

Objectives
• Identify indications and contraindications of SSC
• Describe the principles of tooth preparation and SSC crown preparation,
adaptation and cementation
• Describe steps of anterior teeth preparation and restoration with composite strip
crown.
• Identify Advantage and disadvantage for every crown
• Possible solutions for placement problems
Types of pediatric crowns
Full metal • Stainless Steel Crown
• Nickel-base Crown

• Polycarbonate crowns.

Non metal •
•
Resin (composite) strip crowns.
Zirconia crowns.
• Fiber glass crown

Combination • Pre-veneered steel crowns.

• Open faced steel crowns.
Stainless Steel Crown
 Introduction

• Its prefabricated crown forms, which can be

adapted to individual primary molars and cemented

Stainless
in place to provide a definitive restoration.
• They are considered the most durable and reliable
Steel Crown restoration.
• It is a permanent restoration used in primary &
temporary in young permanent teeth .

History

• It was introduced as chrome-steel crowns by

Humphrey in 1950.
• Now it is commonly called as stainless-steel crown.
 • Neglected carious in small deciduous teeth can
destroy tooth’s faster than in large teeth in
permanent dentition.
Why is SSC used • The deciduous teeth pulp is larger than permanent
more frequently in pulp whereas the enamel and dentin is less in
thickness,
deciduous teeth? • So, it is difficult to make dentinal stump for casted
crown or to use a pin system of retention for more
extensive amalgam restoration.
 Indications
1. Restoration of primary or permanent teeth with extensive carious lesions (more
than two surfaces affected).or When amalgam is likely to fail such as a proximal
box extended beyond line angles.
2. Following pulpotomy or pulpectomy procedures
(teeth become brittle after removal of pulp content and may fracture if not protected).
3. Restoration of teeth affected by developmental problems (e.g. enamel hypoplasia,
amelogenesis and dentinogenesis imperfecta).
4. As an abutment for certain appliances, such as space maintainers.
5. In patients with high caries susceptibility or where routine oral hygiene
measures cannot be performed (handicapped patients).
Advantages
 More superior to multi-surface amalgam restoration with respect to
• Life span,
• Replacement ,
• Retention and resistance.
 They are acceptable to both patient and dentist
 The time for placement is fast compared to other techniques.
 Easy to trim and contour
 Not sensitive technique, may be used when gingival hemorrhage or moisture is
present or when the patient exhibits less than ideal cooperation.
 They are more cost effective because of simple procedure involved in restoring
even severely affected primary molars
Disadvantages

• Aesthetics are extremely poor.

• Some parents may select for extractions in place of restoration of the teeth
Clinical procedures
Primary molars
 (1) Steps of preparations:

(A) Evaluate the preoperative occlusion to check the

following:
1. The opposing tooth has extruded due to long standing
carious lesion.
2. Mesial drift due to proximal caries.
3. Cusp-fossa relation bilaterally.
(B) Local anesthesia administration and
rubber dam application:

• Rubber dam for isolation with the

placement of wooden wedge to avoid
damaging of the adjacent tooth structure.
(C) Tooth preparation:

1. Proximal reduction to open the contact using tapered diamond

stone.
2. Occlusal reduction (1-1.5mm) to avoid occlusal prematurity using
wheel stone.
3. Buccal and lingual preparation is not always necessary except
where there is a large buccal bulge.
4. The preparation should finish with a smooth feather edge
cervically with no step or shoulder.
Deepening of the occlusal
grooves:

Use the tip of the bur ( tapered diamond bur

) to deepen the occlusal grooves by 1- 1.5
mm through the buccal , lingual and
proximal surfaces.
Reduction of the
Cusps:

• Sweep the side of the bur mesiodistally

over each cusp so that the occlusal
surface is reduced by 1-1.5 mm
• comparing the adjacent marginal
ridges and following the original
anatomy except when pulpotomy or
pulpectomy is performed.
Occlusal reduction

A 69L or 169L bur is used to reduce the

occlusal surface by 1-1.5mm .
Proximal reduction

1-Contact is broken so explorer pass between adjacent

teeth.
2-Proximal slices are slightly convergent to occlusal
surface.
3-Feather edge at the gingival crest with no ledges or
shoulder which interfere with crown seating.
4-Proximal slices are smooth.
• Place the wooden wedges in the inter proximal
embrasures,
• The 69L bur is moved B-L across the proximal
surface.
Roundation of sharp edges:

-Proximal line angles should be reduced and

rounded by holding the bur parallel to the long
axis of the tooth and blending all surfaces
together.
-Bevel the occluso-buccal and occluso-lingual line
angles by sweeping the bur mesio-distally
 Three main consideration in selecting the proper SCC:
(D) Crown 1. Adequate mesio-distal diameter.
selection: 2. Light resistance to seating.
3. Proper occlusion height.
2 3 4 5 6 7 size

E
Tooth Mesio-distal diameter Labio-lingual diameter Occluso-cervical length
Mandibular First molar 7.5mm 7.3mm 6mm
Crown size-D3 8.1mm 6.6mm 5mm
D4 8.5mm 6.9mm 5.4mm
D5 8.9mm 7.2mm 5.6mm
D6 9.2mm 7.7mm 6mm
Mandibular second molar 8.6mm 8.8mm 5.5mm
Crown size- E3 9.7mm 8.8mm 6mm
E4 10.1mm 9.1mm 6.3mm
E5 10.6mm 9.6mm 6.6mm
E6 11mm 10mm 6.9mm
Maxillary first molar 6.0mm 8.6mm 5.1mm
D3 6.9mm 7.6mm 5.2mm
D4 7.3mm 8mm 5.4mm
D5 7.8mm 8.4mm 5.9mm
D6 8.3mm 8.7mm 6.1mm
Maxillary second molar 8.4mm 10mm 5.5mm
E3 9.3mm 10mm 6mm
E4 9.6mm 10.3mm 6.3mm
E5 10mm 10.8mm 6.5mm
E6 10.4mm 11mm 6.8mm
Crown adaptation:

1. Try the crown on the tooth, place the

crown on the lingual side and rotate it
toward the buccal side.
2. The crown should extend 1 mm under the
gingival margin.
3. If the gingival extension is too long, using
a crown and bridge scissors cut around the
gingival margin of the crown/then contour
it with a ball and socket plier.
Initial Adaptation of Crown

• The crown should be of a correct length and its margins should be

adapted closely to the tooth
• For shaping the crown margins mark 3 light points on the metal at
the (mesiolingual, lingual and distolingual)and at (mesiobuccal,
buccal, distobuccal) surfaces at the crest of respective marginal
gingiva without compressing the marginal gingiva.
• Final finished margins are placed approximately 1mm below these
marks.
Seating the crown

• Now the crown is tried on the preparation by seating the

lingual first and applying pressure in a buccal direction so
that the crown slides over the buccal surface into the
gingival sulcus
• Resistance should be felt as the crown slips over the buccal
bulge.
Crown contouring
• Initial crown contouring is
performed with a114 plier (ball
and socket plier) in the middle
1/3rd of the crown to produce
belling effect
• This will give the crown more
even curvature
 Crown Crimping
• This is very important to the gingival
Health.
• Using the no.417 crimping pliers the crown
is crimped in the gingival third.
• After completion of crimping there will be
gradual bend in the gingival third of
crown.
• The use of crimping is for the
• protection of soft Tissues.
• provide mechanical retention of the
crown
• protection of the cement from exposure
to oral fluids
 • The crown should be replaced on the
preparation after the contouring
procedure to see that it snaps securely into
place.

Checking the • The occlusion should be checked at this

stage to make sure that the crown is not
final adaptation opening the bite or causing a shifting of
mandible into an undesirable relationship

of the crown with opposing teeth.

• In order to remove the crown, a large

spoon excavator can be used to dislodge
the crown off the tooth.
Finishing And
Polishing
• Plaque formation and gingiva infl
ammation are usually seen due to
rough and unpolished restoration

• To avoid these complications

crown should be polished before
cementation with rubber wheel to
remove all scratches.
 Radiographic confirmation of
the gingival fit

• Before cementation a bitewing is

taken to verify proximal marginal
integrity
Cementation
 SSC should be cemented only on clean dry
mouth, isolation of teeth with cotton roll is
recommended.
 The status of the pulp influence selection of
the cementing material.
 A cavity varnish must be applied before
cementing a crown to a vital tooth
 Rinse and dry the crown inside & outside
and prepare to cement it.
 A zinc phosphate, polycarboxylate or GIC
is preferred.
• Before the cements set ask the
patient to close into centric
occlusion by applying pressure
through a cotton roll and
confirm that the occlusion has
not been altered.
Remove the excess cement
by an explorer or scaler & for
interproximal area can be
cleaned by passing dental
floss through them.
CONFIRM OCCLUSION
RESULT
 1- This usually means that there is
a ledge. It is removed using a
tapered fissure bur.
Crown does not 2- Loss of space:
seat properly • Sometimes loss of space has occurred
!!!!!! because of proximal caries in the tooth
being restored and movement of the
tooth distal to it into the space.
• In this situation, a stainless-steel crown
that will fit on the tooth bucco-lingually is
too large mesio-distally.
Problem while
seating the crown

The crown didn’t seat properly

 Possible solutions to this
problem:
1. The crown is rotated slightly mesio-
buccally so that it is rotated slightly out
of the arch.
2. The closest fitting crown is held in the
beaks of Adams pliers and squeezed
mesio-distally to reduce this dimension.
3. This is an effective way of flattening the
contact points.
 Possible solutions to this
problem:
4. If difficulty is still encountered, additional tooth
reduction of the buccal and lingual surfaces and
selection of another smaller crown .
5. When the area of the space loss is in the region
of the distal surface of a mandibular first primary
molar, a maxillary first primary molar crown for
the opposite side can fit the mandibular tooth.
Placement of adjacent crowns

• Tooth preparation and crown selection

for placing multiple crowns are similar
to the technique described for single
crowns, but with a few additional
factors:
Placement of
adjacent crowns:
1. Prepare the occlusal reduction of one tooth completely before beginning the
occlusal reduction of the other tooth.
1. When reduction of the two teeth is performed at same time , the tendency
is to under-reduce both.
• 2- Insufficient proximal reduction is a common problem. Contact between
adjacent proximal surfaces should be broken producing approximately 1.5 mm
space at the gingival level.
• Crowns should be trimmed, contoured and prepared for cementation at same
time.
• It is generally best to begin placement and cementation of the more distal crown
first. However, the sequence of placement of crowns for cementation should
follow the same sequence as that used when the crowns are placed for the final
fitting.
II. Zirconia
crowns
• are prefabricated strong metal free ceramic
• Most esthetic and biocompatible full
coverage restoration.
• The cervical margin is knife edge to
preserve gingival health.
• Highly polished surface reduces plaque
accumulation.
• Wear is comparable to natural enamel.
They can be autoclaved for sterilizing
 1. Zirconia crowns cannot be crimped and
are not flexible.
2. Passive fit is mandatory.
3. Attempting to seat a zirconia crown with
force will result in fracture.
Disadvantages 4. Adjustment with a bur will result in micro-
fracture; remove glaze or create weakened
areas.
5. The preparation takes more time, and so it
is not recommended for children who are
fearful or unable to cooperate for a longer
procedure
 Preparation
steps

• Selection of crown size is done before the preparation.

• Occlusal reduction should be 1.5 – 2 mm and following the natural
occlusal contours
• Circumferential reduction of 1 – 1.5.
• The preparation margin should be a featheredge and extend about 1 –
2 mm subgingivally (important step).
• The preparation should be parallel, converging slightly to the occlusal
Preparation steps

• All angles of the preparation should be rounded to remove corners.

• There is no contouring, crimping, or trimming a zirconia crown.
• The thin zirconia margins will not flex and may break if forced over a ledge
or bulge. Before cementation, the prepared tooth and the inside of a zirconia
crown should be free of saliva and blood.
• A light activated resin-modified glass ionomer or resin-modified glass
ionomer (RMGI) is recommended for cementation of zirconia cement. Also,
Preparation steps

• Completely fill the crown with a cement to eliminate voids.

• Seat the crown passively with light digital pressure only.
• Do not permit the patient to bite the crown down into occlusion.
• Carefully remove the excess cement while keeping the crown stabilized
• After cement removal, finish curing the cement from buccal, lingual, and occlusal directions
• After cementation, check occlusion with articulating paper.
• If the occlusion is high, it is preferable to reduce the occlusal contact on the opposing primary molar.
Open Faced Stainless
Steel Crown Technique

• Once the cement is set, cut a labial

window in the cemented crown using a no.
330 or no. 35 bur.
• Extend the window: Just short of the
incisal edge.
• Gingivally to the height of the gingival
crest.
• Mesio-distally to the line angles.
• Using a no. 35 bur remove the cement to a
depth of 1mm.
• Place undercuts at each margin with a no. 35
bur or with a no. ½ round bur.
• Smooth the cut margins of the crown with a
fine green or white finishing stone.
• After using a glass ionomer liner to mask
differences in color between remaining tooth
structure and cement place a layer of bonding
agent.
• Place resin-based composite into the cut
window
• forcing the material into the undercuts and
polymerize.
• Add additional material in 1mm
increments and polymerize.

• Finish the restoration with abrasive disks.

• Run the disks from the resin to the metal

at the margins so as not to discolor the
resin with metal particles.
• Repeat the procedure for the
remaining teeth.
• While more aesthetic than a
conventional stainless-steel crown,
• a short coming of an open-faced
stainless-steel crown is the bleeding
of the metal color from the lingual
and interproximal surfaces through
the composite resulting in a grayish
tinge to the facing.
 Advantages
• The aesthetics are fair. (The metal shows through the
composite facing.)
• They are very durable, wear well and retentive.
• The materials are inexpensive.
Open Faced Disadvantages
• The time for placement is long as it involves a two-step

Crowns process (crown cementation/composite facing

placement.
• Placement of the composite facing may be
compromised when gingival hemorrhage or moisture is
present or when the patient exhibits less than ideal
cooperation.
• Although stainless steel crowns, as a standalone
technique for anterior restorations, are rarely used,
mastering the technique is necessary for fabrication of
the more aesthetic open-faced stainless-steel crown.
 • Composite strip crowns are composite filled celluloid
crowns forms.
• superior aesthetics
• Composite strip crowns rely on dentin and enamel adhesion
for retention.

Composite
• Therefore, the lack of tooth structure, the presence of
moisture or hemorrhage contributes to compromised
retention.

Strip Crowns • They are less resistant to wear and fracture than other
anterior full coverage restorations.
• It was found that composite strip crowns had a failure rate
of 51%, compared to an 8% failure rate of stainless-steel
crowns.
• With a cooperative patient, the time required for placement
is comparable to that of a stainless-steel crown and less than
veneered and zirconia crowns.
Advantages
• It provides superior aesthetics.
• The cost of materials are reasonable
• The time for placement is reasonable.
Disadvantages
• It is extremely technique sensitive.
• It is not as durable or retentive as stainless steel/open faced crowns, pre-veneered
crowns or zirconia crowns
• It is not recommended on patients with a bruxism habit or a deep bite.
• Adequate moisture control might be difficult on an uncooperative patient.
 Composite Strip Crowns
Technique

• Select a primary celluloid crown form with a

mesio-distal incisal width equal to the tooth to be
restored by placing the incisal edge of the crown
against the incisal edge of the tooth.
• Remove decay with a medium to large round bur on a
slow speed hand piece.
• If pulp therapy is required, do it at this time.
• Reduce the interproximal surfaces by 0.5 to 1.0mm.
• The interproximal walls should be parallel and the
gingival margin should have a feather edge.
• Reduce the facial surface by 1mm and the lingual
surface by 0.5mm.
• Create a feather-edge gingival margin.
• Round all line angles.
• Trim the selected crown by removing the
collar and the gingival excess material with
crown and bridge scissors.
• Place a small vent hole on the lingual surface
with a bur or explorer to allow escape of
trapped air when the composite filled crown
is seated.
• Fit the crown on the prepared tooth.
• The crown should extend 1mm below the
gingival margin.
• Maxillary lateral incisors are usually 0.5 to
1.0mm shorter than central incisors.
• Select the appropriate shade of composite
(extra light).
• Fill the crown with resin material
approximately two thirds full.
• Etch the tooth with acid gel for 15
seconds, wash and dry the tooth, and
• apply bonding agent. or
• Use a self-etching bonding agent.
• Polymerize.
• Seat the filled crown form on the
tooth.
• Remove the excess material from
the vent hole and the gingiva.
• Repeat the procedure with the
adjacent teeth.
• Polymerize the material from both
the facial and lingual directions.
• Remove the celluloid form by cutting the
material on the lingual with either a composite
finishing bur or scalpel.
• Pry the celluloid form off the tooth.
• Very little finishing is required except for
adjusting the occlusion and
• smoothing gingival margins.
• Use flame shaped and rounded composite
finishing burs for finishing.
• Repeat the procedure for adjacent teeth.
 • Pre-veneered stainless-steel crowns
resolve some of the problems associated
with stainless steel crowns, open-faced
stainless-steel crowns, and composite

Pre-veneered strip crowns.

• They were introduced in the mid 1990’s.

Stainless- • They are aesthetic, placement and

cementation are not significantly affected

Steel Crowns by hemorrhage and saliva and can be

placed in a single appointment.
• The stainless-steel crown is covered on
its buccal or facial surface with a tooth-
colored coating of polyester/epoxy hybrid
composition zirconia.
Advantages

• They are aesthetically pleasing.

• They require relatively short operating time.
• They have the durability of a steel crown.
• They are less moisture sensitive during placement than composite strip crowns.
A clinical disadvantage
• they are relatively inflexible as the facing is brittle and tends to fracture when
subjected to heavy forces or crimping.
• Because only the lingual portion of the crown can be adjusted (crimped),
significant removal of tooth structure must be performed to fit the tooth to the
crown rather than the crown to the tooth.
• There is limited shade choice.
• They are more expensive to than stainless steel crowns and strip crown forms
yet less expensive than zirconia crowns
 Pre-veneered
Stainless Steel
Crown Technique
• Size the crown to the tooth by placing the incisal edge
of the crown against the incisal edge of the tooth.
• Prepare the tooth as for a standard stainless-steel
crown, however more circumferential tooth reduction
required.
• Refine the prep to fit the crown.
• Do not force the crown on the tooth.
• A properly fitted crown has a passive fit.
• The crown should extend 1mm past the gingival
margin.
• The length of the crown is altered by trimming
the gingival margin with a diamond bur and
water spray.
• The lingual aspect of the crown may be crimped
slightly with a no. 137 Gordon plier.
• Too much crimping of the metal substructure
may cause fractures in the veneer material.
• The crown is cemented with glass ionomer
cement.
• The excess cement is removed and the
remainder is allowed to set.
• After cementation the incisal edges may
be contoured with a finishing disk or
point.
• The smaller lateral crowns may be used
on lower anterior teeth.
• Cold sterilization in glutaraldehyde is
recommended.
• If the veneer fractures a similar technique
to the open-faced crown may be used for
repair.
 1. NUSMILE crowns
When a full coverage restoration is needed for
longevity and for protection of remaining tooth
structure,
2. Cheng crowns
Pre veneered These are crowns with a pure resin facing which
crowns make stain resistant less
3. Dura crowns
These are pre veneered crowns are esthetic and can
be placed with poor moisture or hemorrhage
control but they are not easy to fit and require a
long learning curve
3. Zirconia crown
• The preparation for both preveneered and zirconia crowns is
similar to that of
composite resin crown except that
• 1. Greater amount of reduction of all tooth surfaces is required
for both
• Reduce the incisal edge by 2 mm, proximal surfaces by 1.5 mm,
labial surface by 1–1.5 mm and lingual surface by 0.5–1 mm.
• 2. zirconia crowns are tried on until a crown seat passively over
the preparation.
• 3. zirconia crowns are cemented with a resin-modified glass
ionomer or a light-activated resin cement
 Thank you
References
• McDonald and Avery dentistry for the child and adolescent 10th edition .
Restorative Dentistry. CHAPTER 11 :197-205.